Tranexamic acid for upper gastrointestinal bleeding.
Tranexamic acid is a prohemostatic drug with antifibrinolytic properties and has proven to be of benefit in patients with serious blood loss, such as in patients with major trauma or patients undergoing cardiac surgery. Upper gastrointestinal hemorrhage is a frequently occurring clinical situation that may have a deleterious outcome despite causal (usually endoscopic or surgical) or adjunctive (usually anti-acid) treatment. This meta-analysis summarizes the findings of 7 randomized controlled trials of tranexamic acid in patients with upper gastrointestinal hemorrhage. Results show that tranexamic acid reduced mortality compared to placebo (RR 0.61, 95% confidence interval 0.42-0.89). However, in only one out of seven trials all patients underwent endoscopic intervention to treat the bleeding focus and in this individual trial there was no (additive) beneficial effect of tranexamic acid. Also, direct comparison of tranexamic acid with acid lowering treatment did not show any benefit of the antifibrinolytic treatment. Interestingly, despite the positive overall effect on mortality, there was no significant effect on clinically relevant outcome parameters, such as the need for surgery or transfusion rates. In conclusion, this meta-analysis shows that tranexamic acid may be beneficial in patients with upper gastrointestinal hemorrhage; however, the advantage in patients undergoing currently accepted standard treatment including intervention endoscopy in combination with acid lowering agents, such as proton pump inhibitors, need to be demonstrated. All data so far show that treatment with tranexamic acid is relatively safe, which follows the pattern observed in other clinical settings such as trauma and cardiac surgery. In view of this safety and the low costs of tranexamic acid, a clinical trial showing an additive effect of antifibrinolytic treatment on top of current standard treatment is urgently warranted.
– Marcel Levi